Acute Hospitalizations Following Outpatient General Surgery (HFG)

For persons 65 years of age and older, the risk-adjusted ratio of observed-to-expected unplanned acute hospitalizations (inpatient and observation stays) for any diagnosis that occurred within 15 days following select outpatient general surgeries.

Why It Matters

Outpatient, or ambulatory, surgeries are planned surgeries where the patient is not expected to be admitted to an inpatient setting. Though most facilities primarily offer same-day surgeries, some provide extended stay services to patients who need additional recovery time or monitoring 1. Surgical procedures are increasingly moving from the inpatient to the outpatient setting, with over 50 million procedures (translating to about 70 percent of all surgeries) now performed in ambulatory settings each year 2 3.

Many outpatient surgery centers specialize in specific clinical areas, such as orthopedics or cardiology, to enhance efficiency and productivity 4.

Payment arrangements and financial incentives have been a major driver in the transition to outpatient surgery. As of 2020 there were 5,930 ambulatory surgery centers (ASC) in the US that have been certified by CMS to receive full reimbursement for services provided to Medicare beneficiaries. In 2020, Medicare spent $4.9 billion on treatment and procedures at ASCs 5. There has been a growth in the number of ASC facilities and the number of procedures performed in these settings. Between 2015 and 2019 the total number of ASCs increased each year by an average of 2.1 percent, the majority of which were for profit, physician-owned facilities. During the same period there was an average increase of 6.7 percent in payments for ASC services for Medicare fee for service (FFS) members 5.

Studies have found that cost savings for payers for outpatient procedures compared to similar inpatient procedures are significant, ranging from around 15% to 60% depending on procedure type 6 7 8. For example, a study found that outpatient unicompartmental knee arthroplasties were, on average, about $20,000 less per patient than those performed in an inpatient setting 7.

Advances in surgical technologies, perioperative care and payment structures have increased the number and variety of surgical procedures performed in outpatient settings.

The same-day nature of most ambulatory procedures limits the opportunity for direct oversight of patients in the hours and days after surgery, which makes patient surveillance and management of potential complications difficult 9. Care coordination is therefore critical for capturing problems early and ensuring positive patient outcomes. This is true for all outpatient surgery settings but particularly for independent, freestanding ASCs that are not integrated with a larger health system.

Certain patient characteristics and risk factors can increase the chances of complications following outpatient surgical procedures. A study of over 400,000 elective outpatient procedures showed that the risk of complications was significantly higher among patients with frailty compared to those without frailty 10. Another study of 170,000 patients who underwent an outpatient total joint arthroplasty showed an overall complication rate of 8 percent, with a significantly increased risk of complications among patients with malnutrition, history of cardiac problems or smoking, diabetes mellitus and those over age 70 11. While certain risk factors are not independently associated with outpatient surgery complications, studies documented a higher risk of complications when multiple risk factors are present.

The most common reason for hospital visits following nonelective general surgery procedures is surgical site infections, which negatively impact patient outcomes and are associated with significant financial costs 12. Postoperative complications can be better identified and managed through a multidisciplinary approach to postoperative care coordination, technological advancements allowing for improved patient communication and adherence to evidence-based methods during preoperative risk assessments 13.

Historical Results – National Averages

Performance results for this measure are currently unavailable.

References

  1. Steiner, Claudia A., Zeynal Karaca, Brian J. Moore, Melina C. Imshaug, and Gary Pickens. 2020. “Statistical Brief #223: Surgeries in Hospital-Based Ambulatory Surgery and Hospital Inpatient Settings, 2014.” Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. http://www.ncbi.nlm.nih.gov/books/NBK442035/
  2. Gabriel, Rodney A., Ruth S. Waterman, Brittany N. Burton, Sophia Scandurro, and Richard D. Urman. 2021. “Patient Health Status and Case Complexity of Outpatient Surgeries at Various Facility Types in the United States: An Analysis Using the National Anesthesia Clinical Outcomes Registry.” Journal of Clinical Anesthesia 68 (February): 110109. https://doi.org/10.1016/j.jclinane.2020.110109
  3. Hollenbeck, B. K., R. L Dunn, A. M. Suskind, Y Zhang, J. M. Hollingsworth, and J.D. Birkmeyer. 2014. “Ambulatory Surgery Centers and Outpatient Procedure Use Among Medicare Beneficiaries.” Medical Care 52 (10): 926–31. https://doi.org/10.1097/MLR.0000000000000213
  4. Bates, Matthew, Kristofer Blohm, and Nora Kelly. 2022. “Putting Ambulatory Surgery Centers at the Center of Outpatient Strategy.” July 21, 2022. https://www.kaufmanhall.com/insights/article/putting-ambulatory-surgery-centers-center-outpatient-strategy
  5. MEDPAC. 2021. “Chapter 5: Ambulatory Surgical Center Services.” In Report to the Congress: Medicare Payment Policy, 133–60. Washington, DC: MEDPAC. https://www.medpac.gov/wp-content/uploads/2021/10/mar21_medpac_report_ch5_sec.pdf
  6. Crawford, Dennis C., Chuan Silvia Li, Sheila Sprague, and Mohit Bhandari. 2015. “Clinical and Cost Implications of Inpatient Versus Outpatient Orthopedic Surgeries: A Systematic Review of the Published Literature.” Orthopedic Reviews 7 (4): 6177. https://doi.org/10.4081/or.2015.6177
  7. Richter, Dustin L., and David R. Diduch. 2017. “Cost Comparison of Outpatient Versus Inpatient Unicompartmental Knee Arthroplasty.” Orthopaedic Journal of Sports Medicine 5 (3): 2325967117694352. https://doi.org/10.1177/2325967117694352
  8. Tanaka, Miho J. 2019. “Ambulatory Surgery Centers Versus Hospital-Based Outpatient Departments: What’s the Difference?” September 1, 2019. https://www.aaos.org/aaosnow/2019/sep/managing/managing02/
  9. Theissen, A., K. Slim, A. Deleuze, and M. Beaussier. 2019. “Risk Management in Outpatient Surgery.” Journal of Visceral Surgery, Forensic aspects of surgical practice, 156 (September): S41–49. https://doi.org/10.1016/j.jviscsurg.2019.04.005
  10. Rothenberg, Kara A., Jordan R. Stern, Elizabeth L. George, Amber W. Trickey, Arden M. Morris, Daniel E. Hall, Jason M. Johanning, Mary T. Hawn, and Shipra Arya. 2019. “Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery.” JAMA Network Open 2 (5): e194330. https://doi.org/10.1001/jamanetworkopen.2019.4330
  11. Courtney, P. Maxwell, Anthony J. Boniello, and Richard A. Berger. 2017. “Complications Following Outpatient Total Joint Arthroplasty: An Analysis of a National Database.” The Journal of Arthroplasty 32 (5): 1426–30. https://doi.org/10.1016/j.arth.2016.11.055
  12. Rossi, I. R., Ross, S. W., May, A. K., & Reinke, C. E. 2021. “Readmission After Emergency General Surgery: NSQIP Review of Risk, Cause and Ideal Follow-Up.” Journal of Surgical Research, 260, 359–368. https://doi.org/10.1016/j.jss.2020.11.035
  13. Javed, H., Olanrewaju, O. A., Ansah Owusu, F., Saleem, A., Pavani, P., Tariq, H., Vasquez Ortiz, B. S., Ram, R., & Varrassi, G. 2023. “Challenges and Solutions in Postoperative Complications: A Narrative Review in General Surgery.” Cureus, 15(12), e50942. https://doi.org/10.7759/cureus.50942

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